Healthcare Provider Details

I. General information

NPI: 1235495573
Provider Name (Legal Business Name): MARY ANN WORTHINGTON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 SOUTH OCEAN AVENUE PATCHOGUE MEDFORD SCHOOL DISTRICT
PATCHOGUE NY
11772
US

IV. Provider business mailing address

241 SOUTH OCEAN AVENUE PATCHOGUE MEDFORD SCHOOL DISTRICT
PATCHOGUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-687-6440
  • Fax:
Mailing address:
  • Phone: 631-687-6440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number68013890
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: